I am a plastic surgeon in Little Rock, AR. I used to "suture for a living", I continue "to live to sew". These days most of my sewing is piecing quilts. I love the patterns and interplay of the fabric color. I would like to explore writing about medical/surgical topics as well as sewing/quilting topics. I will do my best to make sure both are represented accurately as I share with both colleagues and the general public.

American Flag

Followers

Tuesday, May 31, 2011

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active.

Grand Rounds is taking a break this week. If you would like to host a future edition of Grand Rounds send an email to Nick Genes (you can find his contact info at here). The most recent edition can be found here at Medgadget. Other editions can be found here on the Grand Rounds Facebook page.

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@movinmeat wrote a post recently, A case study in applied ethics, which lead @inwhiteink to write an educational post on decisional capacity

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“Decisional capacity” refers to a person’s ability to make a decision for a specific clinical issue. This issue is usually related to treatment. After assessment, physicians can opine whether someone possesses or lacks decisional capacity for something specific: ……

Appelbaum and Grisso published an important paper that provides a four-point rubric to assess decisional capacity. (At only four pages, it is a short, high-yield article.) Most psychiatrists apply this rubric when assessing decisional capacity in medical settings. …….

Movin Meat’s followup post: Ethics of refusing informed consent

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From twitter: @Mtnmd The Twitter chat that killed Sermo http://bit.ly/ipw4au

Her link is to an article by Joe Hage which I encourage you to read: The Twitter Chat that Killed Sermo | #MedDevice

I’m not a physician. I don’t play one on TV. And I’d never heard of Sermo, the largest online physician community in the US (boasting 120,000 members) until @HJLuks mentioned them the week before.

Mine was an innocent invitation to talk during last night’s #MedDevice chat (Thursdays, 8 pm EST).

As part of NPR's ongoing series, 'The Impact of War,' guest host Allison Keyes explores one of the tragic consequences of combat - burn wounds. Such wounds can subject victims to a painful and unpredictable recovery. Army Lt. Col. Maria Serio Melvin shares her experiences at the military's largest burn center, the Brooke Army Medical Center in San Antonio, TX, where she treated service members injured in the Iraq and Afghanistan wars …………

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Some inspiring stories of healthcare workers during the Joplin tornado

H/T @Mtnmd -- 45 Seconds: Memoirs of an ER Doctor from May 22, 2011

H/T @SeaSpray – Operating Through the Tornado

James D. "Dusty" Smith, MD, and his surgical team were midway through a routine case, the draining of a patient's infected hip, when the tornado hit St. John's Regional Medical Center in Joplin, Mo., Sunday. ……….

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From @scutmonkey, her piece on Psychology Today: The Radical Notion that Doctors are People, Too

Though there are few subjects as immediate to my experience as that described in Gardiner Harris's article in The New York Times, "More Doctors Say No to Endless Workdays," (April 1st, 2011), perhaps the truest indication of my opinion on the matter may be the fact that, upon first glance at the headline, I didn't feel much need to read the rest of the article. More doctors say no to endless workdays? Well, of course we do. Duh. …..

Her tweet of the article led @DarrellWhite to tweet a link to his view on the same topic: Residency Training and the Modern Physician

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H/T to @brainpicker and @ctsinclair for the link to this: Anatomy made of LEGO (photo credit)

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Last Tuesday (May 24, 2011) NPR celebrated Bob Dylan Turning 70. Near the top of the story written by Linda Fahey is a button “Visit FolkAlley.com To Hear The Mix” which links you to a wonderful mix of Dylan music sung by Joan Baez, Tim O'Brien, Rosanne Cash, Jimmy Lafave, many others — and Dylan himself. Thanks NPR.

……..we decided that loops and buttons would be a cleaner alternative.
Here are a few samples to show you what we did: We started with strips of bias-cut fabric, making a sample or two to determine just how narrow we wanted the finished loops to be. ……….

Monday, May 30, 2011

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active.

Medicine has much to be grateful for to war, but I wish we’d find a peaceful way to make these advances.

Here are just a few

In 1718, Jean Louis Petit, a French surgeon, invented a screw tourniquet to control bleeding. The screw tourniquet made thigh amputations possible and reduced the risks associated with amputations below the knee.

Dominique-Jean Larrey (French Army, joined army in 1792) is credited with setting up the first field hospitals (though the golden hour wasn’t known, this provided quicker care) and “flying ambulances” to rapidly evacuate wounded soldiers from the battlefield to the hospital.

The trench warfare of WWI produced extreme facial injuries. Interdisciplinary teams (dentist, plastic surgeons, etc) set a standard for the care of complex maxillofacial injuries.

WWII saw advancements in treatment of shock. Colonel Edward Churchill discovered that shock was not only related to blood fluid loss but also to electrolyte loss. This led to improvements in intravenous solution preparation.

The Korean War provided us with advancements in vascular reconstruction and repair, better understanding of frostbite, and the Mobile Army Surgical Hospital (MASH).

The wars in Iraq and Afghanistan are increasing our understanding and treatment of head injuries and PTSD. They are also leading to major advances in limb prosthetics.

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Thank you to all Veterans and active duty military for your service. Thank you to all the families behind these men and women.

U.S. Military Builds on Rich History of Amputee Care: During every major conflict, combat injuries have caused large numbers of service members to lose one or more of their limbs; in fact, these individuals are one of the most visible and enduring reminders of the cost of war; Military inStep, 09/18/2008

Science Museum: War and Medicine

"Battlefield Surgery 101: From the Civil War to Vietnam"; National Museum of Health and Medicine (2004)

Friday, May 27, 2011

I made this quilt for my nephew when his mother mentioned the one I had made for him previously was getting quite worn. This time I chose to make him a patriotic quilt. I began with the 8-pointed star which was left over from some long forgotten project and used it as the center of the medallion.

The quilt was sort of a personal “round-robin” as I added sections. The quilt is machine pieced and quilted. I finished it in October 2003. It is 77 in X 79 in.

I want to thank Amy, his mom and my sister-in-law, for taking the photos for me. Sorry they don’t show the entire quilt.

This shows the center a little better. As we begin Memorial Day weekend, I want to thank all active and retired military, as well as their families, for the service and sacrifices they have made and make for us all.

The link is to the CNN article by Kyung Lah: Plastic surgery boom as Asians seek 'western' look

The article is an interview of a 12 yo Korean girl, her mother, and Dr Kim Byung-gun (head of Seoul, South Korea's biggest plastic surgery clinic, BK DongYang).

The young girl doesn’t like her eyes and wants to have a double fold created in her eyelids to give her a more western look.

Is it wrong to want to look like another ethnic group rather than your own? Are you slighting your heritage or family if you chose to change your eyes, your nose, etc?

I was taught, as a surgeon, the neoclassical canons of facial attractiveness (1st reference below). These don’t necessarily translate well into all ethnic groups (ie Asians, African-American). Neither does the Marquardt facial mask.

Media and the cross-culture of our society affects the idea of beauty. M. Jain in her college paper (3rd reference below) notes “that women of different generations and locations have felt the globalization of a Western ideal- skinny, "white" features, tall, and non-curvaceous body.”

Is it a form of self-hatred to want to change the identifying ethnic trait -- Asian eyelids, Mediterranean nose (ie Roman), African-American nose? Is this somehow different than someone who wants more hair, wants bigger/smaller breasts, fuller buttocks, anti-aging cosmetic surgery?

REFERENCES

1. History and Current Concepts in the Analysis of Facial Attractiveness; Bashour, Mounir; Plastic & Reconstructive Surgery. 118(3):741-756, September 1, 2006.

Wednesday, May 25, 2011

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active.

I’m not a huge fan of transaxillary breast augmentation (TABA). One of the major selling points for the transaxillary approach is the lack of scars on the breasts. As a woman living in the south, my arm pits are much more likely to be seen in public than my breasts.

As a surgeon, I also know that when revisions need to be done (capsule issues, etc) most recommend using an inframammary approach so why not just start there. In my opinion, all women with implants will have a repeat surgery at some point in the future – implant failure (deflation, rupture) being a given.

I admit I had not thought about how the incision might interfere with future sentinel lymph node assessment prior to this article (full reference below).

Dr. Ana Claudia Weck Roxo, Rio de Janeiro State University, Brazil and colleagues conducted a small study to evaluate changes in axillary lymphatic drainage in patients who underwent TABA.

The authors share this information as to why this is important (bold emphasis is mine):

The sentinel lymph node is the first node in the lymphatic chain and the first to receive tumor cells via lymphatic drainage. Therefore, sentinel lymph node analysis allows physicians to predict the status of the lymphatic chain. The recent validation of the capacity of the sentinel lymph node to stage breast cancer patients and to help identify those who require axillary dissection has dramatically improved surgical treatment and reduced morbidity. Thus, sentinel lymph node biopsy has become an alternative to axillary dissection in patients with T1 and T2 breast cancer and is a gold standard for axillary staging because of its high sensitivity (84%-98%) and low false-negative rates (2%-8.8%). Nevertheless, it is contraindicated in patients with palpable axillary metastatic lesions, multicentric breast disease, previous mammary or axillary radiotherapy, and/or previous axillary or mammary procedures.

The prospective study enrolled 27 patients who underwent preoperative mammary lymphoscintigraphy, a subsequent TABA (using a subglandular placement of round, textured, high-profile silicone implants through a 4-cm incision at the anterior axillary fold), and postoperative lymphoscintigraphy at 21 days and six months after the procedure.

The postoperative imaging results examining the axillary lymphatic chain and the first axillary lymph node were analyzed and compared to the preoperative images.

None of the patients showed any changes between the preoperative and postoperative images at six months. Only one of the 27 patients (4.5%) demonstrated a lower rate of lymphatic drainage at 21 days postoperatively compared to preoperative values.

The sentinel lymph node remained visible in all patients at all time points, and all breasts showed drainage primarily to the axillary lymphatic chain.

Their data showed preservation of lymphatic drainage and visible sentinel lymph nodes even after transaxillary breast augmentation. I would love a larger study to confirm, but am pleased they looked at this.

Tuesday, May 24, 2011

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active.

Medgadget is the host for this week’s issue of Grand Rounds! You can read this week’s edition here.

Welcome to Grand Rounds, the weekly recap of the best in the medical blog universe! And welcome to Medgadget, where our team of researchers, doctors and engineers cover the world of medical devices and health-related technology news.

For Grand Rounds this week, we suggested bloggers send us technology-related material, and they rose to the challenge; we received some amazing links. Of course, there was great non-techie material too. It’s all below, loosely categorized, with photos and quotes lifted from posts of note. …….

An Austrian resident has voluntarily had his hand amputated so he can be fitted with a bionic limb.

The patient, called "Milo", aged 26, lost the use of his right hand in a motorcycle accident a decade ago.

….. what is called a "brachial plexus" injury to his right shoulder left his right arm paralysed. Nerve tissue transplanted from his leg by Professor Aszmann restored movement to his arm but not to his hand. ….

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angienadia, MD, Primary Dx, has written a thoughtful post on resident work hours which can be read both on her blog or on KevinMD: New ACGME work hour regulations for interns: friend or foe?

…..Libby highlighted what was and is wrong with medicine today. Private physicians cannot and should not be allowed to manage patients who are sick enough to be admitted by phone – ………

The solution stares us in the eye – interns need a stricter cap on the number of patients they can admit or care for at one time. …... Sixteen-hour shift is not the answer – it only aggravates the actual source of the problem

Patients are often a source of inspiration and hope.
One such stand out individual is Nathan Charles.

I first met Nathan in January of this year in my role as team doctor for the Emirates Western Force rugby union team. Nathan is a 21 year old elite athlete playing number 2 (hooker) for the Western Force. But what makes this achievement even more admirable is that he has cystic fibrosis. …………

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NPR’s Robert Krulwich writes about women in science: The Ghost Of Madame Curie Protests...

……….. I got to thinking about the not-so-subtle way women have been treated in science, even the most celebrated ones.

A few months back, I wrote a post about how the Nobel Committee (a committee of guys) in 1911 tried to get Madame Curie NOT to come and collect her second Nobel Prize. ……….

Fellow medical blogger @DrJohnM wrote about some things he observed on his recent trip to Germany: A Kentucky Doc goes to Europe

……..For now, may I highlight a few of the more striking differences between Europe and the States, as noted by a Kentuckian on his first trip across the Atlantic?

(I realize that sophisticated well-traveled people already know this stuff, but I can’t help myself.)

First...The transportation system in Europe uses much smaller vehicles……….

Second…The bikes! I was stunned by the sheer numbers of smart-looking people pedaling around on the sidewalks and streets of Hamburg……….

On healthcare:

(A disclaimer: I am only making observations and asking questions; I am not suggesting we adopt the German healthcare system after a five-day visit.)

I quickly learned that all German citizens get free healthcare. But those who desire ‘more’ care can buy additional private coverage. ……….

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You can find some of my iPhone photos here. They are not nearly as good as the ones in this HuffPost Arts article from John Seed: The Art of iPhone Photography in Orange County (PHOTOS)

If Cartier-Bresson was still taking photos today, he would ditch his Leica and be taking photos with an iPhone. At least, that is the view of Knox Bronson, a curator, composer and iPhoneographer who has been gathering a stunning gallery of iPhone photos on his site: P1XELS the art of the iPhone.

Bronson, who is a purist, is only interested in collecting photos that have not in any way been manipulated outside of the phone by a computer:

This is one of mine (Instagram photo app with Inkwell filter of a pink rose in full bloom):

Monday, May 23, 2011

It seems that over the years I have ended up with a different Norton Anti-virus product key for three different computers rather than one for all three. The renewal emails are staggered through the spring.

This week I decided to tackle the issue and see if I could get it changed. I visited the website and when I saw the option of contacting them via twitter I did just that.

Twitter worked!

I sent my question to @nortonforumsusa which began an email correspondence. Within less than 24 hours I had all three computers running Norton 360 Premier under the same product key.

The first contact, TL, even forwarded my question regarding refund or credit from the other two to customer relations rep RV who gave me two options (I chose the credit one).

One reason it worked for me was I did my homework before I contacted them. I helped them help me by having all three product key numbers available, giving them a working email address, and responded to their questions quickly.

This post is simply meant to be a public expression of gratitude and thanks for how well Norton’s customer service worked. Thanks to TL and RV.

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But I will take it further ----

Perhaps hospitals and clinics could use twitter the same way for non-emergency/non-diagnostic/non-treatment issues like billing, scheduling, etc.

First, a public request for help. Second, take the help to a private venue (email or phone).

Saturday, May 21, 2011

Updated 3/2017-- all links (except to my own posts) removed as many no longer active.

Last year I didn’t write about dog bite prevention until the first week of June even though I know National Dog Bite Prevention Week is always the third full of week of May.

The numbers shared by the American Veterinary Medical Association (AVMA) haven’t changed: 4.7 million people are bitten by dogs each year in the US with 800,000 of them requiring medical attention.

If you have read this blog for very long, you know I dearly love my dogs -- deceased ones (Columbo, Ladybug (photo), and Girlfriend) and the living one, Rusty. Still, I have no illusions that dogs bite and given the right provocation, I think mine would though most of the time they are totally harmless and would just invite you in to rob me.

Sadly, children are by far the most common victims of dog bites, occurring most often in children 5-9 years of age. Senior citizens are the second most common dog bite victims.

Children are also more likely to be severely injured and represent half of the dog-bite victims requiring medical attention every year. Almost two thirds of injuries among children 4 yrs or younger are to the head or neck region.

The family pet is often to blame, so it is important for parents to teach their children how to treat dogs. It is also important to train the family dog in obedience.

Dog bites are a largely preventable public health problem. There are a number of things that you can do to avoid dog bites.

Take care in selecting a family pet. Obedience training and socializing the pet beginning at a young age will insure the dog feels at ease around people and other animals. Keep the dog healthy.

Don't put your dog in a position where it feels threatened or teased. Teach your children not to tease the family dog or any other dog. Neutered dogs are less likely to bite.

NEVER leave a baby or small child alone with a dog.

Basic safety around dogs
• Do not approach an unfamiliar dog.
• Do not run from a dog and scream.
• Remain motionless (“be still like a tree”) when approached by an unfamiliar dog.
• If knocked over by a dog, roll into a ball and lie still (“be still like a log”).
• A child should not play with a dog unless supervised by an adult.
• A child should immediately report stray dogs or dogs displaying unusual behavior to an adult.
• Avoid direct eye contact with a dog.
• Do not disturb a dog who is sleeping, eating, or caring for puppies.
• Do not a pet a dog without asking permission from its owner first.
• Do not pet a dog without allowing it to see and sniff you first.

Source
American Veterinary Medical Association (AVMA)
American Kennel Club
United States Postal Service

Thursday, May 19, 2011

Updated 3/2017-- all links (except to my own posts) removed as many no longer active.

I stumbled across this review article (first full reference below) earlier this week.

Skin cancer is the most common form of cancer in the United States. Most skin cancers form in older people on parts of the body exposed to the sun or in people who have weakened immune systems (such as inflammatory bowel disease patients on immunosuppressive therapy).

According to the National Cancer Institute (NCI), in there were more than one million new cases of nonmelanoma skin cancers (NMSC) in the United States in 2010. There were less than 1,000 NMSC deaths during the same time.

NMSC includes squamous cell carcinoma (SCC) and basal cell carcinoma (BCC). Both occur more frequently on sunlight-exposed areas such as the head and neck. BCC is far more common than SCC and accounts for approximately 75% of all NMSC.

The causes of NMSC in the general public are multifactorial, including both environmental and host factors. Known environmental risk factors for NMSC include sun exposure (ultraviolet [UV] light), ionizing radiation, cigarette smoking, and certain chemical exposures such as arsenic. Host risk factors include human papilloma virus infection, genetic susceptibilities, skin type, and immunosuppression.

That last risk factor mentioned – immunosuppression—is one IBD patients have in common with solid organ transplant patients (kidneys, livers, lungs, face, hands). Note the third reference below. The results summary of that article

Two hundred patients developed a first NMSC aftera median follow-up of 6.8 years after transplantation. The 3-yearrisk of the primary NMSC was 2.1%. Of the 200 patients witha primary NMSC, 91 (45.5%) had a second NMSC after a medianfollow-up after the first NMSC of 1.4 years (range, 3 monthsto 10 years). The 3-year risk of a second NMSC was 32.2%, andit was 49 times higher than that in patients with no previousNMSC. In a Cox proportional hazards regression model, age olderthan 50 years at the time of transplantation and male sex weresignificantly related to the first NMSC. Occurrence of the subsequentNMSC was not related to any risk factor considered, includingsex, age at transplantation, type of transplanted organ, typeof immunosuppressive therapy, histologic type of the first NMSC,and time since diagnosis of the first NMSC. Histologic typeof the first NMSC strongly predicted the type of the subsequentNMSC

Attention is now being paid to other patients (ie IBD, rheumatoid arthritis) on immunosuppression and their increased risk of NMSC.

Millie D. Long, MD and colleagues (first reference) note that no IBD-specific, evidence-based guidelines for NMSC prevention exist. The current recommendations for prevention of skin cancer for the general population include sun avoidance and sun protection strategies include protective clothing, hats, sunglasses, and sunscreens. Sun avoidance should include tanning bed avoidance.

Any skin lesion suspicious for malignancy in a patient with IBD on immunosuppression should be evaluated by a trained dermatologist. Among solid-organ transplant recipients, annual skin examination is recommended by various transplant organizations.

Long and colleagues note “There are no guidelines for skin cancer screening in patients with IBD, as it is unclear whether the risk–benefit ratio of skin cancer screening in IBD patients correlates with that of the general population, or more closely with that of the solid-organ transplant population. Consideration could be given in the future to skin cancer screening programs for patients with IBD on immunosuppression.”

Use sunscreen, SPF 15 or above, preferably one with a sunblock component also. To protect against the UVA rays, the product needs to have avobenzone (Parsol 1789), ecamsule (Mexoryl), titanium dioxide, or micro-zinc oxide.

Sunscreens should not be used in babies under 6 months old. It is recommended by the American Academy of Pediatrics for this group to use other sun safe practices such as the ones just mentioned.

Tuesday, May 17, 2011

Updated 3/2017-- photos/videos and all links (except to my own posts) removed as many no longer active.

Prepared Patient Forum, What it Takes is the host for this week’s issue of Grand Rounds! You can read this week’s edition here.

We received more than 40 contributions for this week’s collection of health care blogs and columns. Patients, clinicians, policy wonks and interesting folks with opinions submitted original posts that are sure to expand your thinking and perspectives. …..

On Calling the Shots, Beth Gainer takes issue with using terms such as “sexy” and “sassy” to describe the experience of having breast cancer. As a breast cancer survivor, Beth understands the reality of the diagnosis, treatment and aftermath that left her feeling anything but sexy or sassy.

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Paul Levy, Not Running a hospital, on health care policy: The Whac-A-Mole school of health care policy

Boy, if you ever needed a summary of how messed up our health care system is, check out this story by Robert Pear in the New York Times. Entitled, "Nursing Homes Seek Exemptions From Health Law," the essence is that nursing homes want to be exempt from the employer requirement to provide health care benefits to their staff because the payments nursing homes get from Medicare and Medicaid to deliver care to patients are too low to provide enough cash to those institutions to offer those benefits. …..

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A lovely post on humanity by Jordan, In My Humble Opinion: I'm Coming Home

As the door opened the look on her face was undeniable. Grief. Pain. the tears rolled down her eyes. She let me into her small dorm room and hugged me. And then she told me that her grandmother was dead.

She was a mess. Her sadness was overwhelming. She sat on her bed in a stupor. And I sat with her. Holding her hand. Not saying a word. Just being…..

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Dr. Smak writes about what grief has taught her: Reflections

………….Last week our moderator asked us to reflect on how we have changed, what we have learned, from our experience as a bereaved parent. There were several things mentioned, and much overlap as expected. These stood out for me: …….

3. Finally, what I'm still struggling to learn: life goes on. Not his life, but everyone else's. …. As one father put it, "My other children are still growing up." …... I don't want to miss out twice. And I don't want her to miss out on having a present mom.
Being a bereaved parent hasn't made me a better person, but I'm different than I was.

Brought to my attention via @MotherinMed and @enochchoi: Magic of the MD-patient relationship NYT: Our Health and the Luck of the Draw

Sometimes you hear stories from your patients that leave you staggered by the caprice of life. A young West African patient told me how his extended family had trudged through the forest on foot to escape rebels. He was 10 years old at the time. At one point in the journey, he had to urinate. He excused himself and retreated several feet into the bush. Moments later shots rang out. When he finally had the courage to crawl back out onto the path, he saw that his entire family had been killed in an ambush. …….

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I feel even more fortunate to have never been sued as I read the statistic “6 in 10 doctors are sued by the time they reach age 55, said a 2010 report by the American Medical Association.” This comes from the AmedNews article by Alicia Gallegos: Life after lawsuit: How doctors pick up the pieces

Before dawn, nearly every morning in the days leading to his trial, Stephen Lutz, MD, woke abruptly, his mind filled with thoughts of the looming witness stand.

He would spend the next few hours lying in the darkness, going over the case again and again.

"I awakened many mornings rehearsing what I would say to explain myself. It's almost as if I was giving testimony every morning at 4 a.m.," said Dr. Lutz, a radiation oncologist in Ohio who was sued in 2008.

Experts say such stress associated with a medical liability lawsuit manifests in different ways, often affecting all aspects of a physician's life. ……

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How cool would it be to go to a concert and be invited on stage? Well, NPR tells the story of just that happening to Rayna at a Paul Simon concert: Paul Simon And A Moment Of Pure Sobbing Joy

Paul Simon has brought joy to so many for so long, but on this night he made Rayna Ford's dream come true. During a show in Toronto on May 7, Rayna Ford, a fan from Newfoundland, called out for Simon to play "Duncan," and said something to the effect that she learned to play guitar on the song. In a moment of astonishment and disbelief, Paul Simon invited her on stage…...

Monday, May 16, 2011

Updated 3/2017-- all links (except to my own posts) removed as many no longer active.

Four years ago I began this blog. It amazes me to realize all the wonderful people I have meet (some even in real life) along the way. Many are still actively writing, but others are not and I miss them.

I miss SurgeXperiences, a grand rounds of surgery related posts.

I miss Surgeonsblog. Go read some of the “sampler” posts.

I miss Ant Ears written by a surgery resident. Thoughtful, well written, deleted so not even there to go back and read. From one of my old “shout out” post, I found the exert that described why he called his blog Ant Ears

"Ant ears” is surgical jargon for the perfect length. The medical student will repeatedly be asked to cut suture. Sometimes the knot will accidentally be cut, but most times the student will cut “too long” or “too short”. Fifty or more attempts will usually produce a reliable knot cutter capable of trying more advanced techniques like tying suture around some non vital structure - maybe closing skin or holding a drain in place.

I miss Dr. Rob, Musing of a Distractible Mind, who “unplugged” back December 30, 2010. He has recently re-emerged on twitter so perhaps he will begin to write again.

I wonder what happened to Bright Lights, Cold Steel, “a surgery resident in the fifth and last year of training. Desperately seeking balance,” who’s last post was in 2008. Are you in private practice? Have you joined a group? Are you an academic surgeon? I hope you are doing well.

While Moof, All Blogged Up: A Moof's Tale, and the Merry Laundress don’t blog any more, I get to play scrabble with them on facebook. I correspond with Chrysalis Angel via email.

There are others I miss as well:

Charmaine's Pastry Blog (last post December 2010)

Donorcycle (last post February 2010)

IntraopOrate (last post January 2011)

Just Up The Dose (last post October 2009)

Marianas Eye (November 2009)

Rural Doctoring (last post August 2010)

I apologize to all of you for not being as active in leaving comments on your blog posts these days. Thank you for enriching my life.

Friday, May 13, 2011

Updated 3/2017-- all links (except to my own posts) removed as many no longer active.

Two years ago I made a quilt for the Alzheimer’s Art Quilt Initiative (AAQI). This is my second quilt for them.

It is machine appliqued and quilted. The center “heart” fabric is from a silk tie who’s theme was in the guise of “Where’s Waldo?” but involved Santa. The confusion and fun inspired me to make this small quilt I call “Let’s Go.” Let’s go on a trip and make some memories.

I cut out the road signs and the red car from some Route 66 fabric had I used for a previous quilt.

Here is Santa in the middle of the zoo.

The quilt is 9 in X 11.5 in. I used the fast triangles method for hanging.

I have registered and mailed the quilt. It is not up for sale or auction on the site yet, but will be in the future as quilt #7034.

Wednesday, May 11, 2011

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active.

You may recall that last year I wrote regarding the un-fair use of medical bloggers post and twitter feeds:

Fellow bloggers do you remember Wellsphere? Well, the latest “thief” of our information using our reputations and twitter feeds in a similar way is Organized Wisdom. Check out @laikas recent blog post on the topic: Expert Curators, WisdomCards & The True Wisdom of @organizedwisdom

Organized Wisdom (http://organizedwisdom.com and @organizedwisdom on Twitter) is a 3-4 year old company that uses a similar approach to filter useful health information out of the daily junk. ……

Part of the problem may be that Organized Wisdom doesn’t only share links from “Health Centers”, but also from Wellness Centers (Aging, Diet, Exercise & Fitness etc) and Living Centers (Beauty, Cooking, Environment). Apparently one card can have information for 2 or 3 centers (diabetes and multivitamins for example)

I feel used.

Organized Wisdom uses the credibility of me and other curators, including so-called “top expert curators” as Dr Pho (Kevin MD – blog), to cover up the incredibility of others, with the intention to lure users in. ……..

Just as with Wellsphere, I have asked Organized Wisdom to remove me from their expert curator list. I hope you will do the same.

……

Well it continues. A new acquaintance on twitter, @medmarketingcoe, has written an article: Unethical Health Information Content Farming by Organized Wisdom (OW) & how 5700 social media Curators participate in major ethical, legal, & moral violations without their knowledge

Laikas (@laikas) has written another post on the same topic: Health Experts & Pt Advocates Beware: 10 Reasons Why U Shouldn’t be Curator

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What do you think of this screenshot from yesterday? Isn’t it misleading? How does this help provide clear and accurate information for the general public? You know the “I am a plastic surgeon in Little Rock, AR. I may ‘suture for a living’, but I ‘live to sew’” is straight from my blogging profile, but it appears to be the statement being made about each of the doctors in the screenshot below. This is a misrepresentation of each of those doctors.

Cynthia Bailey, MD blogs at Dr. Bailey's Skin Care Blog. She is a dermatologist and does not live in Little Rock, AR. Her own blog states she practices in California.
FaceLiftMD twitter profile states he is a “Board Certified Facial Plastic Surgeon specializing in Cosmetic Surgery of the nose, face, neck, eyelids, & eyebrow in DC, Maryland, and northern Virginia.” Once again, he does not live in Little Rock, AR.
Vijay, Scanman, is a radiologist who lives and works in Salem, India. He blogs at scanman's notes and posterous.
……
Once again, I encourage my fellow healthcare bloggers (doctors, nurses, patient advocates, etc) to remove yourself from any association with Organized Wisdom and other sites like them.

Updated 3/2017-- all links (except to my own posts) removed as many no longer active.

Here are a few new items on stem cells and fat grafting I’ve come across recently.

First are a couple of nice posts by fellow plastic surgeon/blogger Dr. Thomas Fiala, the Orlando plastic surgery blog who is attending The Aesthetic Meeting 2011 in Boston this week.

Live from Boston: Fat grafting controversies !! (May 6, 2011)

……It's pretty clear that fat grafting works, and can be done safely. There seem to be two major methods that work……

One bit of consensus: if the breast was not pre-expanded, you can't expect to get more than 100 cc of fat to survive.

ASAPS 2011: Best of Hot Topics (May 9, 2011)

Here are my choices for the "Hot Topics" presented at the Boston ASAPS meeting:

1. "Stem Cell Facelift" - Dr. Peter Rubin reviewed the literature on the so-called Stem Cell facelift. It turns out that there really is no consistent technique for this method. Many advertised "stem cell facelifts" are simply regular facelifts with regular fat grafting and don't involve any extra stem-cell work at all. Furthermore, to date, there is NO DATA that this technique is superior to facelift with standard fat grafting. Summary: as of today, the stem cell facelift can either be considered unproven and under development, or if you are a little more cynical, it might just be "marketing hype".

The review by Rubin was highlighted in a press release: ASAPS and ASPS Issue Joint Position Statement on Stem Cells and Fat Grafting on Monday, May 9, 2011.

….. Based on the current state of knowledge, the task force made the following recommendations to ASAPS/ASPS members and their patients:

Terms such as "stem cell therapy" or “stem cell procedure” should be reserved to describe those treatments or techniques where the collection, concentration, manipulation, and therapeutic action of the stem cells is the primary goal, rather than a passive result, of the treatment. For example, standard fat grafting procedures that do transfer some stem cells naturally present within the tissue should be described as fat grafting procedures, not stem cell procedures.

The marketing and promotion of stem cell procedures in aesthetic surgery is not adequately supported by clinical evidence at this time.

While stem cell therapies have the potential to be beneficial for a variety of medical applications, a substantial body of clinical data to assess plastic surgery applications still needs to be collected. Until further evidence is available, stem cell therapies in aesthetic and reconstructive surgery should be conducted within clinical studies under Institutional Review Board approval, including compliance with all guidelines for human medical studies. ………….

And the last item comes from the PRSonally Speaking Blog: Articles of Interest Sneak Peak: Breast fat grafting with platelet-rich plasma: a comparative clinical study and current state of art. It highlights the abstract of an article which will be published in the PRS journal in June 2011.

The role of Platelet-Rich Plasma (PRP) in enhancing fat grafts take is attracting the scientific community. However, there is a lack of clinical series on the matter.

The aim of this paper is to report Authors' experience in breast fat graft with and without PRP and to investigate the state-of-art on adipose tissue PRP enrichment……

Conclusion: In Authors' retrospective analysis no effect of PRP was seen in enhancing fat graft take when compared to Coleman fat graft. Further research and prospective clinical studies are strongly needed to understand the role of PRP, if any, in fat grafting.

Tuesday, May 10, 2011

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active.

ePatient Dave is the host for this week’s “TEDx Maastricht” issue of Grand Rounds! You can read this week’s edition here.

Welcome to Grand Rounds for May 10, 2011!
I have a confession: I’m new at this. My initial exposure to Grand Rounds a while back gave me a warped view, and as I worked on this project, I was a little bit graceless. (Those of you who wrote to me about it know what I mean. I meant well…)
This week’s theme is the TEDx Maastricht conference that happened April 4. But first -These news highlights were submitted:

Dr. Ed Pullen’s “Medical blog for the informed patient” is not thrilled about Vimovo, a new drug for osteoarthritis. Pullen believes in letting people know what’s going on behind the scenes. …

Some exciting news! 'Coppla: A Pediatric Surgeon in Iraq' has won the 2011 Montaigne Medal, the Eric Hoffer award... http://fb.me/AE0vuaIA

Chris blogs at “Coppola: A Pediatric Surgeon in Iraq”

……………………………….

Shared on twitter by @EllenRichter “Wonderful way to end Nurses Week! What an honor! "First #Nurse Nominated as Army Surgeon General" http://goo.gl/IJq3A” (photo credit)

Maj. Gen. Patricia Horoho would become the first nurse and the first woman to serve as the Army Surgeon General if the Senate confirms her nomination and simultaneous promotion to lieutenant general, which were announced by Defense Secretary Robert Gates on Tuesday.

Horoho currently serves as Army deputy surgeon general and 23rd chief of the U.S. Army Nurse Corps. …

…………………………….

Did you every read “The House of God” by Samuel Shem, MD? Fellow blogger @inwhiteink shared a link on twitter to a wonderful essay by Shem: Fiction as Resistance (pdf)

I was a writer before I was a doctor. From an early age I was concerned with suffering and understanding, and I often turned to stories for solace. I loved stories long before I knew they were an essence of good doctoring—shared stories that bring solace, understanding, and healing to others. …... My early answers to the question, “What is healing?” came from these stories. I still have a piece of an envelope on which I copied part of a letter Chekhov wrote to an editor who had criticized his story “Ward Number Six”: “The best of writers are realistic and describe life as it is, but because each line is saturated with the consciousness of its goal, you feel life as it should be in addition to life as it is, and you are captivated by it” (1).

Life as it should be in addition to life as it is. Without
realizing it until many years later, this would become the motor of my writing. ……….

…………………….

This past Sunday I caught this interview by CBS Sunday Morning of Christy Turlington discussing her life and her new project “Every Mom Counts

Ever wonder what type of tree you have encountered in the park or on a walk? Nick Genes, MD (@blogborygmi) tweeted about a new (free) iPhone app which identifies trees from photos of the leafs from on twitter: For The High-Tech Naturalist: LeafSnap Identifies Leaves Using Your iPhone’s Camera (photo credit)

I’d like an app like this for identify edible wild greens/foliage.

……………………………………..

Just How Dangerous Is Sitting All Day? [INFOGRAPHIC] (photo credit) -- Remember to get up and move!

Monday, May 9, 2011

Updated 3/2017-- all links (except to my own posts) removed as many no longer active.

Recently I attended a CME course entitled “Dealing with Difficult Colleagues.” It was part of my medical malpractice company’s risk management series to teach physicians/nurses how to lessen our risk of being sued.

This lecture was given by Linda Worley, MD who is a psychiatry professor at UAMS. She is a good speaker, easy to understand, engages the crowd, and knows her subject.

My only complaint would be it focused only the “angry” or “frustrated” physicians who exhibit unprofessional behavior and did not include the ones whom you suspect might be difficult due to impairment (illness, drugs, alcohol).

Here are some of the A-B-C-D strategies given for handling “horizontal” hostility (or hostility handed from one person to another to the next in the team):

Acute Awareness

Recognize verbal and non-verbal behaviors

Do not ignore and let them grow

Remember, they are often driven by distress

Be a leader

Set a good example

Refuse to engage in negativity

Communicate assertively

Acknowledge conflict

Respect others’ views

Move to a private area

Dedicate yourself to making positive difference in the workplace

Don’t participate in gossip, infighting or backstabbing

Make daily deposits into the emotional bank accounts of others

When assertive communication is used in dealing with the difficult colleague both parties will feel they matter. You should include “I” statements so the difficult colleague doesn’t feel attacked. You should describe the situation/needs objectively. It is always a good thing to give a genuine POSITIVE statement about the other person. Confront your difficult colleague with honesty and compassion.

It is helpful for an office, clinic, or hospital to have a defined Code of Conduct as this sets up expectations and clearly defines appropriate behavior. It also facilitates an objective discussion as it can be referred to as needed.

Friday, May 6, 2011

This is a quilt I made years ago (unsure as I failed to put a label on this one) using challenge fabric for a contest (didn’t finish in time). I thought I recalled it being for a Hoffman challenge, but apparently not as the fabric doesn’t match any of the fabric of past challenges. So if anyone recognizes the fabric ….

I believe it was early 1990’s, around 1993. I combined three blocks: prairie queen, shoe fly, and flying geese.

The quilt is machine pieced and quilted. It is 34 in square. Here is a close up of the fabrics. Here is the back which is made of the remaining gold fabrics. Even though there is a sleeve on this for hanging, I use it to cover an old desk in my bedroom.

Thursday, May 5, 2011

Updated 3/2017-- all links (except to my own posts) removed as many no longer active.

I was alerted to the presentation at the American Society of Breast Surgeons meeting (first reference below) by Judy Boughey, MD by @MedicalNews’ tweet:

ASBS: Prophylactic Mastectomy Good Even Years Later (CME/CE) http://bit.ly/kMCsdr

Boughey and colleagues note that previous researchers using cross-sectional surveys have found that the majority of women are satisfied with their decision to have contralateral prophylactic mastectomy (CPM) one to several years after the procedure.

Their study chose to look at the consistency of satisfaction and changes in adverse effects in the same women with longer term follow-up.

To do this, they surveyed a previously established cohort of women with unilateral breast cancer who had contralateral prophylactic mastectomy at the Mayo Clinic between 1960 to 1993. All of the women had a positive family history. All were surveyed at two time points and the results compared.

The initial survey was done at a mean of 10.3 years after prophylactic mastectomy (second and third references below). This survey involved 583 women.

Of the 583 women who responded to the initial survey, 523 were alive and resurveyed 10 years later. Data from both surveys are available for analysis on 269 women.

The researchers found the majority of women continued to be satisfied with their decision to have contralateral prophylactic mastectomy (86% initial survey; 90% follow-up survey, p=0.06).

Similar numbers to that of the initial survey reported neutral feelings or dissatisfaction with their CPM decision on follow-up survey (8% and 6%, respectively, initial survey; 4% and 6% follow-up survey).

There was no significant change in the proportion indicating they would choose CPM again, but as with satisfaction, the proportion was slightly higher on the follow-up survey (95% initial survey; 97% follow-up survey, p=0.27).

From the MedPage News article: "This information is useful in the education of patients and physicians," said Boughey. "Patients should consider their choice carefully and be made aware of adverse events. However, those that decide for contralateral prophylactic mastectomy are likely to remain satisfied with the decision in the long term."

A related post of interest is one from Dr. Dialogue: Is Watchful Waiting too Difficult? (originally posted there on March 13, 2010 and on Better Health on May 1st, 2011: Why Double Mastectomies Are Popular: Watchful Waiting Is Too Difficult?)

Wednesday, May 4, 2011

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active.

Here’s the tweet I posted Sunday evening:

I've told pts this for years now>>> Liposuction Study Finds That Lost Fat Returns - http://nyti.ms/kheltN

The New York Times article reports on a liposuction study published in the April issue of the journal Obesity (full reference below). The NY Times article uses this photo as graphic illustration

and a quote from a plastic surgeon who says he is surprised.

Dr. Felmont Eaves III, a plastic surgeon in Charlotte, N.C., and president of the American Society for Aesthetic Plastic Surgery, said the study was “very well done,” and the results were surprising. He said he would mention it to his patients in the context of other information on liposuction.

I have told my patients for years to consider the fat cells in their body as drawers or storage bins. If I take away some of the drawers and they continue to take in “fat” that needs to be stored, the body will put it somewhere. If there are now fewer drawer options in the saddlebag or abdominal region, then where will it go? Most likely the upper body, etc.

This article does more definitively define the answer to where it will be placed.

The study enrolled 32 healthy women (mean age 36) with disproportionate fat depots (lower abdomen, hips, or thighs) were enrolled and then randomly placed into either a small-volume liposuction group (n = 14, mean BMI: 24 ± 2 kg/m2) or control (n=18, mean BMI: 25 ± 2). Participants agreed not to make lifestyle changes while enrolled.

The surgery group had their liposuction within 2-4 weeks of the baseline measurement. Identical measurements were repeated at 6 weeks, 6 months, and 1 year later.

After 6 weeks, percent body fat (%BF) by DXA was decreased by 2.1% in the lipectomy group and by 0.28% in the control group (adjusted difference (AD): −1.82%; 95% confidence interval (CI): −2.79% to −0.85%; P = 0.0002).

This difference was smaller at 6 months, and by 1 year was no longer significant (0.59% (control) vs. −0.41% (lipectomy); AD: −1.00%; CI: −2.65 to 0.64; P = 0.23).

The fat (adipose tissue) reaccumulated differently across various sites.

After 1 year the thigh region remained reduced, but fat (adipose tissue) reaccumulated in the abdominal region. Following suction lipectomy, BF was restored and redistributed from the thigh to the abdomen.

…..

I do not find this surprising. Once the drawer is removed, it can not store items any longer.

If you only liposuction the lower abdomen (area below the umbilicus), those patients are likely to return with increased fat in the upper abdomen. It needs to be keep in proportion.

Tuesday, May 3, 2011

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active.

The 2011 Arkansas Medical Society Annual Meeting was this past weekend. Each year two awards are given: the Asklepion Award and the Shuffield Award.

The Asklepion Award is presented to an AMS member physician who promotes the art and science of medicine and the betterment of public health; embodies the values of the medical profession through leadership, service, excellence, integrity and ethical behavior; and enriches patients, colleagues and the community through dedicated medical practice.

This year’s recipient of the Asklepion Award is Morriss M. Henry, MD. He is a retired ophthalmologist in Fayetteville who has been active in both medicine and in our state government since he began his practice in 1961. He served as president of the AMS in 1982 and has served on multiple boards. Dr. Henry served in the Arkansas legislature as State Representative (1967-1971) and State Senator (1971-1984). He has been involved in many community endeavors, including the development of the Jones Eye Institute at UAMS and Hobbs State Park.

The Shuffield Award is the highest honor in the medical community for a non-physician. It recognizes an Arkansas who has done outstanding community work in the health care field. The Shuffield Award is named in memory of Doctors Joe and Elvin Shuffield, a father and son physician team from Little Rock, who devoted their lives to improving the quality of health care in this state.

This year’s recipient of the Shuffield Award is Charles ‘Ship’ Mooney, Jr. He has practiced law in Jonesboro, Arkansas for the past 28 years. The award was given to him for the work he has done as the founder of “The Out of the Dark Movement” which he started in the fall of 2008. He was spurred into action after reading in his local paper the report of 5 heroin overdoses in community youths. His first action was to write a letter to the editor which was published. This resulted in a public meeting regarding the issue at which 250 people showed up. One hundred of them signed up to help try to solve local issues caused by chemical addiction in their community. They now have more than a thousand volunteers. (photo credit)

Shared on twitter by @docgurley -- “Here's an article every American should read: An outsider's view of our journalists' coverage of healthcare reform: http://ow.ly/4I0bQ”

As a Brit looking back on the AHCJ conference which ended just a week ago, I have to say that the overwhelming impression I took away was that Americans appear to love their health insurance companies more than almost anything else, and that US health journalists appear to be less critical and analytical in approaching health reform and health policy than when they report on new drugs and treatments. …….

In fact, eleventh cousins is a pretty low degree of relatedness, by the standard of these things. A study of inbreeding in European populations found that couples from the UK are, on average, as genetically related as 6th cousins (the study looked at inbreeding in Scots, and in children of one Orkadian and one non-Orkadian. No English people, but I would be very suprised if we differed significantly). 6th cousins share about 0.006% of their DNA, and thus have about a 0.06% chance of developing a genetic disease via a common ancestor. …..

Every major industry is now computerized with one glaring exception; health care delivery. Thirty years after Steve Jobs began selling personal computers out of his garage, far less than 50% of physician practices and hospitals have converted to any form of electronic medical record.

I read the article, but kept coming back to this one paragraph. Do you know of any other industry who is not allowed to raise their fees to pay for the implementation of adding this new technology to the business? I can’t think of any. Cost is one of the big barriers here.

Monday, May 2, 2011

Updated 3/2017-- all links (except to my own posts) removed as many no longer active.

The FDA General and Plastic Surgery Devices Panel of the Medical Devices Advisory Committee met on April 27, 2011 to review the request for expanding the use of Restylane for augmentation of the lips. The panel voted 6 to 0 (1 abstaining) that Restylane for lip augmentation is generally safe and effective for this purpose and that the benefits outweigh the risks.

The FDA still has to make a final decision on Restylane injectable gel for lip augmentation, but the agency usually follows the advice of its advisory panels, which consist of outside experts.

Restylane was approved by the FDA in 2003. It is a non-animal stabilized hyaluronic acid gel. Restylane is free from animal proteins. This limits any risk of animal-based disease transmissions or development of allergic reactions to animal proteins. Allergy pretesting is not necessary.

Perlane is a more robust form of Restylane intended for use in the deep dermis and at the dermal-fat junction. Restylane is indicated for the correction of moderate to severe facial wrinkles and folds.

The most commonly observed side effects are temporary redness and swelling at the injection site, which typically resolve in less than seven days. Both are made by Medicis. Both are available with lidocaine (Restylane-L, Perlane-L). Patients should be limited to 6.0 mL per treatment.

According to Medicis, Restylane is the most-studied aesthetic dermal filler in the world, and has been used in over 10 million treatments worldwide.

From Medscape news article:

During the public comment portion of the meeting, Gloria Duda, MD, board-certified plastic surgeon from McLean, Virginia, who was representing the American Society for Aesthetic Plastic Surgery, noted that Restylane is commonly used off-label to augment and contour the lips, and she encouraged the panel to support its use for this indication.

Lip augmentation is a "very frequently" requested procedure, Dr. Duda said, and, in her experience, the results are "immediate and reproducible and the risks with hyaluronic acid are minimal."

"I perform over 120 lip augmentations per year with no complications and 95% retention with return visits at 8 to 12 months for repeat procedures," Dr. Duda said.

General and Plastic Surgery Devices Panel of the Medical Devices Advisory Committee. Meeting held April 27, 2011, in Gaithersburg, Maryland.

Sunday, May 1, 2011

Updated 3/2017-- video and all links (except to my own posts) removed as many no longer active.

American Idol covered Carol King's songs this past week. Haley Reinhart did “Beautiful.” The words are a reminder of a simple way to be beautiful.

You've got to get up every morning with a smile on your face And show the world all the love in your heart Then people gonna treat you better You're gonna find, yes, you will That you're beautiful as you feel …..

Carol King puts it much more beautifully than the essay by Robert Tornambe, M.D.: What Makes a Person Ugly?
Here is Carol King singing “Beautiful” live. Enjoy

Disclaimer

My purpose in writing my blog is to attempt to provide good solid medical information on topics of my choosing. It is a way to educate myself, my colleagues, and the general public. References will be provided on medical posts, but not on opinion essays or poetry posts. An additional purpose is to share my interest in quilting topics, a way to show my human side.

Any medical information provided by this site is not a replacement for medical diagnosis, treatment, or professional medical advice. It should not be used to treat or diagnose any medical condition. Always seek professional medical consultation by a licensed physician for diagnosis and treatment of any and all medical conditions - please, do not ignore your doctor's medical advice based on information written by the author or commenters of this site. Please do not ask me for medical advice, but instead contact a healthcare provider in your area. Anything written about office/hospital situations/events are fictional examples to get a point across. No patient is/will ever be a specific patient (unless given written permission), but a fictional one. To know more about how I handle medical information about patients please link here. Unless, I am praising a colleague, even those will be fictional. Any similarities to you or people you know is purely coincidental. My husband and I, and our dogs are fair game.

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